Application Form For Office Use Only:

Section A Application Number:

EQUAL OPPORTUNITIES – THIS SECTION OF THE FORM WILL BE NOT BE FORWARDED TO SHORTLISTING PANEL

LGCA is working towards equality of opportunity for all who apply for employment with the organisation. We are actively opposed to discrimination and want to ensure our processes support recruitment of the full diversity of people. We believe that monitoring our recruitment results will help us assess any areas requiring improvement. To assist us with this, we would be grateful if you would complete this form and return it alongside your application. Your help in this matter is entirely voluntary and will in no way affect your application.

LGCA undertakes that this form will not be made available to anyone involved in the recruitment process and will remain confidential to the Trustees to be used solely for the purpose of monitoring our equal opportunities policy’s effectiveness.

Please indicate your gender: ________________________________________________________

Please indicate your age: 16 – 25 26 – 35 36 – 45 ☐ ☐ ☐ 46 - 55 56 – 65☐ 65+☐ ☐

Ethnic origin is not about nationality, place of birth or citizenship.

Please describe your ethnic origin: ________________________________________________________

Do you consider yourself to have a disability within the meaning of the Disability Discrimination Act 1995? (See end of this part of form for definition) Yes ☐ No ☐

We fully support the social model of disability and we recognise that people with different impairments or medical conditions can experience different barriers. If you have selected yes, please select the nature of your disability:

Physical/sensory impairments ☐ Learning difficulty & specific learning difficulties ☐Mental health difficulties ☐ Medical conditions ☐

Thank you for your assistance

Disability Definition - Individuals who were registered under the Disabled Persons (Employment) Act 1944 on both 12 January 1995 and 2 December 1996 are treated as being disabled under the Disability Discrimination Act

1995 (DDA). The DDA states “a person has a disability if he has a physical or mental impairment which has a substantial and

long-term adverse effect on his ability to carry out normal day to day activities.” The person must satisfy the four criteria in bold in the above statement to fall under and, therefore, be protected under the DDA.

This definition is subject to amendments made by the DDA 2005.

Please email info@lydegreenca.org if you require this form in another format, such as large print.

Application Form For Office Use Only:

Section B Application Number:

Please note that if you have a disability and you require having this form, or submitting the information with regard to this form in another format, such as in larger print, please contact us via email on info@lydegreenca.org.

Post Applied For: Centre Assistant

Location: Lyde Green Community Centre

How did you hear about this vacancy?

Personal DetailsFamily Name (Including Preferred Title)

First Name(s)

Address (Inc. Postcode)

Contact Telephone No:

E-mail Address

National Insurance Number

Are you eligible to work in the UK? YES ☐ NO ☐

Please state what documentation you can provide to demonstrate this e.g. British Passport, EEA ID card, passport or travel document showing an authorisation to reside and work in the UK

Note: Should you be short listed, you will be asked to bring this documentation with you to the interview. A full

list of eligible documents will be sent to you. Any offer of employment will be subject to successful verification of your right to work in the UK.

Safeguarding Children, Young People & Vulnerable Adults

We are committed to safeguarding and promoting the welfare of our services users. We expect all staff to share this commitment and to undergo appropriate checks. Any offer of appointment is subject to satisfactory DBS (Data Barring Service) Disclosure Check.

Do you have a DBS certificate?

If so, please provide the number, date of issue and date of birth:

Have you ever been the subject of an investigation or enquiry into abuse of, or inappropriate behaviour with children or young people and vulnerable adults?

YES ☐ NO ☐

Are you aware of any police enquires undertaken following allegations made against you, which may have a bearing on your suitability for this post?

YES ☐ NO ☐

If yes, please give full details on a separate sheet

Criminal Convictions

This appointment is excluded from the non-disclosure provisions under the Rehabilitation of Offender Act 1974. Applicants must declare any convictions which for other purposes are “spent” and in the event of employment, failure to disclose such convictions could result in dismissal or disciplinary action. Any information will be treated confidentially.

Have you ever been convicted of a criminal offence by a Court of Law? YES NO ☐ ☐

Are you currently under investigation, awaiting trial, verdict or sentencing in any criminal proceeding?

YES NO ☐ ☐

If yes, please give details below or on a separate sheet including the offence and the date.

Applications from people with disabilities, or those with health problems, who meet the essential criteria are welcome and will be given full consideration. Please let us know in the space below if you have any access requirements at interview, or if there is anything you would like to make us aware of:

Data Protection Statement

The information that you provide on this form and that obtained from other relevant sources will be used to process your application for employment. The personal information that you give us will also be used in a confidential manner to help us monitor our recruitment process.

If you succeed in your application and take up employment with us, the information will be used in the administration of your employment with us and to provide you with information about us or a third party via your pay slip. We may also use the information if there is a complaint or legal challenge relevant to this recruitment process. When your employment ends with us, or if you are not successful, we will destroy your data in line with our data protection policy.

We may check the information collected, with third parties or with any other information held by us. We may also use or pass to third parties, information to prevent or detect crime, to protect public funds, or in other ways as permitted by law.

By signing this application form we will be assuming that you agree to the processing of sensitive personal data (as described above), in accordance with our registration with the Information Commissioner's Office.

DECLARATION

I acknowledge that LGCA is committed to safeguarding and promoting the welfare of children and young people and to this end hereby certify that I am not on List 99, disqualified from work with children, or subject to sanctions imposed by a regulatory body such as GTC, and have no convictions, cautions or bind-overs (or have attached details of my record in a sealed envelope marked confidential).

I declare to the best of my knowledge and belief, all particulars I have given in all parts of this application form are complete and true. I understand that any false declaration or misleading statement or a significant omission may disqualify me from employment and render me liable to dismissal. I understand that any job offer is subject to references, checks on relevant qualifications, employment eligibility and criminal convictions, and (where required) a medical report, all of which must be deemed by LGCA as satisfactory.

I also declare that I will not contact any member of LGCA to further this application (and I understand that to do so would disqualify me from further consideration) - unless the advertisement invites me to contact a named

individual to seek further details.

Signed Date

Section A and B of the Application Form will be detached prior to short-listing. Panel members will not have details of your personal information until after short-listing has been completed.

Application Form For Office Use Only:

Section C Application Number:

Present Post DetailsName and address of current employer:

Telephone Number:

Date of appointment to organisation (DD/MM/YY):

Job Title

Contract Type TEMPORARY PERMANENT ☐ ☐

Date of appointment to post, if different (DD/MM/YY):

Type of Appointment: FULL-TIME PART-TIME ☐ ☐

Salary/Allowance Details:

Reason for Leaving:

Date free to start if appointed (DD/MM/YY):

Previous EmploymentPlease list your most recent position first and continue on a separate sheet where necessary

Name and address of employer Position held StartDate

EndDate

Reason for leaving

Please use the space below to explain any gaps in your employment.

Previous Employment with Children

Other than the employment mentioned above, have you ever worked within a role (paid or voluntary) that involved contact with children or young people?

YES ☐ NO ☐

If yes, please provide details below. LGCA reserve the right to contact any of your previous employers.

Name and address of employer Position held(Please state if Full-time or

Part-time)

Start Date

(mm/yyyy)

End Date

(mm/yyyy)

Reason for leaving

Education

Date School/College/University Subjects Taken Examination Results/Grades

Other Professional Qualifications including membership of Professional Bodies

Other Experience Relevant to the Post e.g. Work Experience, Voluntary Positions, Personal Interests

If you need to give further information, please continue on a separate sheet

RefereesPlease give the name and address of two people whom we may contact for a reference. One of these should be from your current or most recent place of employment, although LGCA reserves the right to contact any of your former employers.

Please note that we may contact these referees if you are short listed for this post and might wish to seek references before interview. Also, in relation to work with children, we will seek information about any past disciplinary issues relation to children and/or child protection concerns you may have been subject to. If you have any concerns about this, please do not hesitate to contact us.

1st Referee 2nd Referee

Name

Status/Position

Organisation

Relationship

Address

Tel. No.

E-mail address

Is this referee aware of your application for this post?Yes No ☐ ☐

Are you willing for this referee to be approached prior to interview?Yes No ☐ ☐

Is this referee aware of your application for this post?Yes No ☐ ☐

Are you willing for this referee to be approached prior to interview?Yes No ☐ ☐

Application Form Section D

Post Applied For: Centre Assistant

Name:

Please complete the following sections, using additional space if necessary.

1.

How do your personal qualities and professional experience qualify you for this position?

Please refer to the Job Description and give examples of how your qualifications/skills/experience meet the essential and desirable specifications of the role.

This is the section that your application will be scored on, so please state as much evidence as possible.

2. How you would seek to incorporate the LGCA vision and values into your working practice?

End of Application

Please return completed applications and any additional information by email to info@lydegreenca.org

By returning this application electronically, you are confirming that the information is true and accurate to the best of your knowledge. If you are shortlisted for the post you will be required to sign a hard copy of your application form prior to interview.

If you require an alternative method for submission of your application, please get in touch via email at info@lydegreenca.org or call Aymie Elkins-Green on 07809 750545 or Bob O’Brien on 07779 069966